Code_of_Ethics

To: John Smith From Anne Carino Date: May 28, 2010 Re: Audit of Medical Records Mr. Smith: Recently I conducted an audit of medical records with a diagnosis of bacterial pneumonia. I was quite alarmed to find that 65% of all the medical records researched were not supported by the proper documentation. When I questioned the staff they stated that the Medical Cheild of Respiratory Medicine informed them that “there are other ways to determine bacterial pneumonia other than a lab culture”. They further stated that there were told that they should just assign the code for bacterial pneumonia. According to the AHIMA Code of Ethics certain principles need to be strictly adhered to when updating client’s files. I found numerous violations to these ethics and they are as follows: 1). Advocate, Uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information. 1.1. Protect all confidential information to include personal, health, financial, genetic, and outcome information. This by law was not followed through because the charts were automatically coded for “bacterial pneumonia” without the proper “outcome information” based on certain tests. 1.2. Engage in social and political action that supports the protection of privacy and confidentiality, and be aware of the impact of the political arena on the health information system. Advocate for changes in policy and legislation to ensure protection of privacy and confidentiality, coding compliance, and other issues that surface as advocacy issues as well as facilitating informed participation by the public on these issues. This by law was not adhered to because the charts were not in compliance with regards to coding. 2. Put service and the health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the health information management profession. 2.1. Act with integrity, behave in a trustworthy manner, elevate service to others above self-interest, and promote high standards of practice in every setting. This by law was broken because the practice that was used with regards to the patient’s file was not “consistent by acting honestly and responsibly. 2.7. Take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests. This by law was discarded by the Medical Chief of Respiratory Medicine when he had his staff improperly code the files of his patient’s. 4. Refuse to participate in or conceal unethical practices or procedures. 4.1. Act in a professional and ethical manner at all times. Neither the staff nor the Medical Chief acted in a professional or ethical manner when corners were cut on their clients. 4.3. Be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations. Again neither the staff nor the Medical Chief is aware of the AHIMA Code of Ethics because of the discrepancy in the files. 4.6. Participate in, condone, or be associated with dishonesty, fraud and abuse, or deception. A non-inclusive list of examples includes: This by law was broken because: A. Codes were assigned without physician documentation. B. Coding was incorrect because the documentation does not justify the procedures that were billed. C. Miscoding to avoid conflict with others. The staff did not wish to go against the Chief with regards to coding irregularities. D. Engaging in negligent coding practices. E. Hiding or ignoring review outcomes, such as performance data. My suggestion to the staff on how to avoid these issues in the future would be to review the AHIMA Code of Ethics so that they are well educated, and understand exactly what the code is all about. Also, to avoid any conflict between staff and medical professionals always seek the guidance of someone in management who can intervene and correct the situation immediately. Thank you for your time. Sincerely, Anne Carino Acknowledgement Adapted with permission from the Code of Ethics of the National Association of Social Workers. Resources National Association of Social Workers. "Code of Ethics." 1999. Available at http://www.naswdc.org. AHIMA Code of Ethics, 1957, 1977, 1988, and 1998 [pic] ----------------------- MEMO